Employer use of transparent PBMs have more than doubled in the past year, compared with employer use of the Big Three PBMs, according to the results of the 2025 Pulse of the Purchaser survey, conducted by the National Alliance of Healthcare Purchaser Coalitions (National Alliance) and its member coalitions.

The “Big Three” PBMs—CVS Caremark, Express Scripts and OptumRx—controlled approximately 57% of the market in 2023. However, in the last year, employer use of the Big Three has fallen from 72% to 61%, while employer use of transparent PBMs has risen from 12% to 31%, the survey notes. Additionally, other PBM use has declined from 16% to 8%.

Most employers (53%) also strongly agree that rising healthcare costs impact their ability to compete. In 2022 only 35% of employers strongly

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